The use of antibiotic-loaded bone cement combined with tibial intramedullary nail as last resort treatment in 11 elderly patients with knee joint bone infection

The use of antibiotic-loaded bone cement combined with tibial intramedullary nail as last resort treatment in 11 elderly patients with knee joint bone infection | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The use of antibiotic-loaded bone cement combined with tibial intramedullary nail as last resort treatment in 11 elderly patients with knee joint bone infection Wei Li, Lei Zhang, Yang li, Yong chen, Zhao Xie, Quankui Zhuang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4367527/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The management of bone infections has always posed a challenge in the field of orthopedics, and geriatric knee joint bone infections are even more difficult. In this study, we aimed to assess the clinical efficacy of using antibiotic-loaded bone cementcombined with tibial intramedullary nail as a last resort treatment option for geriatric knee joint bone infection patients. Methods The retrospective study was conducted on 11 elderly patients with knee joint bone infection. The cohort comprised 3 male and 8 female patients, with an average age of 74.27±3.47years. Of these patients, 4 patients experienced reinfection after knee revision replacement, while 7 patients had knee joint bone infection.After stage-1 infection control, all patients underwent a stage-2 treatment using antibiotic-loaded bone cement combined with tibial intramedullary nail as the ultimate treatment approach. Results All patients’ infections were effectively controlled. The average length of bone defect after debridement was 12.09±1.22cm. The duration of the stage-2 operation averaged180.27±11.06minutes. Postoperatively, there was no significant discrepancy in the length of the patients’ lower limbs. All patients experienced a significant enhancement in knee joint function, as indicated by the decrease in WOMAC scores from 141.45±11.75preoperatively to 79.09±0.34postoperatively. Pain levels saw a profound reduction, plummeting from 26.27 ± 2.45 to a non-existent 0.00 ± 0.00. Additionally, there was a substantial improvement in performing daily activities, rising impressively from 59.09 ± 0.34 to 100.55 ± 8.37. However, an increase in joint stiffness was noted, worsening slightly from 15.45 ± 1.63 to 20.00 ± 0.00.One case of peri-implant fracture occurred. Conclusion Antibiotic-loaded bone cement combined with tibial intramedullary nailing as last resort treatment can be considered as an alternative surgical option for elderly patients with knee joint bone infection who have experienced multiple failed operations and long-term knee stiffness. reinfection after knee revision replacement knee joint bone infection bone defect tibial intramedullary nailing antibiotic-loaded bone cement Figures Figure 1 1. Background Bone infection has always been a challenging problem in the field of orthopedics, often leading to lifelong disabilities, even endangering life [ 1 – 3 ]. For patients with stiffness, reinfection after knee revision replacement, and a large extent of bone infection, knee joint fusion may be a more ideal surgical option[ 4 , 5 ]. Knee joint fusion, while beneficial, comes with several potential disadvantages. One common issue is leg length discrepancy post-surgery, a consequence of shortening the affected limb to enhance bone healing at the fusion site. Studies have reported limb shortening ranging from approximately 2.5 to 5.4 cm associated with knee arthrodesis procedures[ 6 – 11 ]. A second concern is the frequent insufficiency of autologous bone available for patients undergoing this procedure[ 12 , 13 ]. Although extensive autologous bone grafting is a recognized method to facilitate healing, factors such as the patient’s advanced age and prolonged inactivity can lead to significant osteoporosis, thereby diminishing bone density[ 14 , 15 ]. Other notable complications associated with knee joint fusion include persistent infections, nonunion at the fusion site, and elevated healthcare costs[ 16 – 18 ]. Recently, some scholars have achieved certain success by using bone cement combined with internal fixation as an ultimate treatment for addressing the limitations of knee joint fusion in patients with knee joint bone infection[ 19 – 22 ]. Since 2014, our team has utilized antibiotic-loaded bone cement combined with tibial intramedullary nail as the ultimate treatment approach for 11 elderly patients with knee joint bone infection. 2. Materials and Methods 2.1. Materials This is a retrospective study in which we reviewed and analyzed data from 11 patients with knee joint bone infections who were treated at our hospital’s Bone Infection Reconstruction Center from July 2014 to July 2022. The cohort comprised 8 females and 3 males with an average age of 74.27 years, with the youngest being 70. Among them, 4 experienced reinfection after knee joint revision replacement and 7 had knee joint bone infection (Table 1 ). All patients underwent a two-stage treatment approach involving an initial surgery to control the infection, followed by the use of antibiotic bone cement combined with tibial intramedullary nail as the ultimate treatment technique.The surgical methodology was rigorously evaluated and received approval from the Institutional Review Board (IRB) of our hospital’s Medical Ethics Committee, adhering to the highest standards of ethical practice and patient consent. All methods were carried out in accordance with relevant guidelines and regulations(IRB No: 20140714-10) Table 1 Details of patients who underwent antibiotic-loaded bone cement combined with tibial intramedullary nail as the ultimate treatment for elderly knee joint bone infection Case Gender Age(y) Main diagnosis Site Side Stiffness(Y/N) Length of bone loss(cm) Shortened length of limb(cm) Times of surgery Ultimate operation duration (minuter) Follow-up period(month) 1 F 73 Chronic osteomyelitis distal femur left Y 13 0.7 - 187 60 2 F 71 Chronic osteomyelitis distal femur right Y 14 0.5 - 176 54 3 F 76 Reinfection after revision replacement knee joint Left - 12 1.0 4 201 47 4 M 78 Reinfection after revision replacement knee joint Left - 13 0.5 3 173 38 5 F 70 Chronic osteomyelitis proximal tibia right Y 10 0.7 - 167 36 6 F 72 Chronic osteomyelitis distal femur left Y 12 0.3 - 190 28 7 M 73 Reinfection after revision replacement knee joint right - 11 0.6 4 189 37 8 F 81 Chronic osteomyelitis distal femur and proximal tibia left - 11 0.8 - 178 35 9 F 73 Chronic osteomyelitis distal femur and proximal tibia right - 11 0.9 - 185 24 10 F 78 Chronic osteomyelitis distal femur left - 13 0.8 - 165 26 11 M 72 Reinfection after revision replacement knee joint right - 13 0.5 5 172 29 ±S - 74.27 ± 3.47 - - - 12.09 ± 0.37 0.66 ± 0.21 - 180.27 ± 11.06 37.64 ± 3.51 2.2. Operative technique (Fig. 1 ) Stage 1 - Infection Control: The procedure begins by exposing the infected region surrounding the knee joint. Any present internal fixation or prosthetic material in the affected area is removed. The surgical team meticulously debrides the site, removing all inflammatory granulation and necrotic tissue. During this process, tissue samples are collected for subsequent pathological and microbiological analysis. Debridement continues until healthy bleeding bone, often referred to as the ‘paprika sign’ is evident, indicating the limit of infection clearance. For extensive segments of infected bone, en-bloc resection may be necessary, and patellectomy is performed if deemed essential. The area is then lavaged sequentially with hydrogen peroxide, saline, povidone-iodine solution, and again with saline to reduce the bioburden to a minimal level. The resultant cavity is filled with an antibiotic-loaded bone cement (PALACOS®R + G*,Heraeus Group,Germany), using a mix ratio of vancomycin to cement of 5:1. To maintain structural stability, external fixation is applied, utilizing either dedicated external fixation devices or an external fixator to secure the bone ends. Stage 2 - Definitive Treatment: Approximately 6 to 8 weeks following the initial surgery, contingent upon the patient’s clinical presentation, imaging results, and laboratory findings indicating infection control, the second-stage surgery is commenced. This phase involves the use of antibiotic-loaded bone cement combined with tibial intramedullary nail as a definitive therapeutic measure. Begin the removal process by carefully disassembling the external fixation device or fixator. Reopen the initial surgical incision to access the defect area. Employ an osteotome with precision to chisel away the bone cement that fills the defect. After the cement has been removed, meticulously prepare the terminal bone surfaces to promote an optimal interface and adhesion for the subsequent application of new bone cement. Thoroughly irrigate the site with a sequence of hydrogen peroxide, saline solution, povidone-iodine solution, and another round of saline to cleanse the area. Careful selection of the tibial intramedullary nail from Double Medical Technology Co., Ltd., China, is imperative, ensuring that its length and diameter are tailored to the patient’s specific tibial anatomy. During the procedure, the chosen intramedullary nail is inserted along the tibial medullary canal. It is positioned so that its proximal end can be retracted into the femoral medullary canal for optimal alignment. Once the nail is withdrawn into the correct position, with its end secured within the femoral canal, it’s locked in place to ensure stability between the femur and tibia. Throughout the procedure, attention is given to preserving the alignment of the femur and tibia, as well as ensuring limb length equality. Using fluoroscopic guidance, locking screws are carefully driven and tightened at both the proximal and distal ends of the nail to achieve a robust stabilization of the joint. Commence by thoroughly mixing one sachet of bone cement with the monomer until a homogenous consistency is obtained. Proceed to meticulously pack this mixture into the medullary cavities at both the femoral and tibial ends. This serves to securely anchor the intramedullary nail in place at each extremity. Subsequently, measure the defect and prepare an adequate quantity of the bone cement mixture to fill the void completely. Once the bone cement has been confirmed to have set firmly, place a drainage tube to prevent fluid accumulation. Finally, suture the wound with precision to promote optimal healing. Three days postoperatively, the patient was able to bear weight with the assistance of crutches. 2.3. Outcome measures Preoperative, intraoperative, and postoperative documentation must include specific metrics to assess the surgical outcome and patient recovery: Preoperative Documentation: Record the Western Ontario and McMaster Universities Osteoarthritis Index (WOWAC) score[ 23 ] of the knee joint to assess the baseline functional status. Document the number of prior surgical procedures performed on the affected limb. Intraoperative Documentation: Measure and record the length of the bone defect following debridement of the infected lesion. Note the duration of the surgical procedure. Postoperative Documentation: Document the WOWAC score of the affected limb at the final follow-up to evaluate the outcome. Measure and record any discrepancy in the length between both lower limbs. Catalog any surgery-related complications, such as recurrent infections or peri-implant fractures. 2.4. Statistical Analysis Data will be analyzed using IBM SPSS Statistics software, version 26.0. For continuous variables, a one-sample Student’s t-test will be utilized to compare the means across groups. Categorical data will be evaluated using the Chi-square test. A P-value of less than 0.05 will be considered statistically significant, indicating meaningful differences between the datasets under examination. 3. Results All patients successfully completed the surgery, and bone infections were effectively controlled in all cases. Among the patients, 8 out of 11 were female and 3 out of 11 were male, with an average age of 74.27 ± 3.47 years. The average length of bone defect after debridement was 12.09 ± 1.22 cm, and the duration of the last surgery was 180.27 ± 11.06 minutes. The average follow-up time post-surgery was 37.64 ± 11.64 months (Table 1 ). One case experienced a peri-implant fracture, which was treated with open reduction and internal fixation. Postoperatively, there was no significant difference in the length of both lower limbs among all patients (0.66 ± 0.21 cm). The knee joint function of patients improved significantly after surgery, with the WOMAC total score significantly higher than preoperatively (141.45 ± 11.75 and 79.09 ± 0.34, P < 0.05). The improvement in function was mainly reflected in pain (26.27 ± 2.45 and 0.00 ± 0.00, P = 0.00) and difficulty in performing daily activities (100.55 ± 8.37 and 59.09 ± 0.34, P = 0.00). However, there was a decrease in knee joint stiffness compared to preoperative levels (15.45 ± 1.63 and 20.00 ± 0.00, P = 0.01) (Table 2 ). Table 2 Comparison of WOMAC scores of knee joint in the pre-operation and postoperation pre-operation postoperation p-value WOMAC pain scores 26.27 ± 2.45 0.00 ± 0.00 0.00 WOMAC stiffness scores 15.45 ± 1.63 20.00 ± 0.00 0.01 WOMAC function scores 100.55 ± 8.37 59.09 ± 0.34 0.00 WOMAC scores 141.45 ± 11.75 79.09 ± 0.34 0.00 Note: 10 points for those who cannot walk or need assistance with crutches Discussion Knee joint fusion is a safe and effective treatment option for patients with knee joint bone infections accompanied by stiffness, as well as for patients who experience recurrent infections after knee joint replacement.Literature reports indicate that the fusion rate for knee joint fusion in patients with postoperative infections after knee joint replacement can be as high as 89%[ 16 ]. However, some studies have pointed out that while the fusion rate is relatively high in the patients, there is also a higher incidence of complications such as internal fixation failure, delayed bone healing, and pseudarthrosis, which are approximately37.6%[ 24 , 25 ]. These complications may pose a significant burden for some patients. In our study, we applied antibiotic-loaded bone cement combined with tibial intramedullary nailing as the ultimate treatment for 11 elderly patients with knee joint bone infections. After a follow-up period of 37.64 months, the WOMAC scores were significantly improved compared to preoperative scores. Postoperative limb shortening and a large amount of bone grafting are disadvantages of knee joint fusion for the patients[ 26 , 27 ].In our study, there was no significant difference in the lengths of the patients’ lower limbs postoperatively, which was better than what is reported in the literature for knee joint fusion patients.For elderly patients, bone quantity has always been a challenging issue due to bone loss. In our study, we not only addressed the problem of limited bone sources but also avoided iatrogenic damage to other parts of the patient’s body. Custom-made intramedullary nails are biomechanically appropriate for the knee joint fusion, are easy to operate, and have the best therapeutic effect[ 23 , 28 – 32 ]. However, its biggest drawback is the high cost.In our study, considering the high cost of custom-made intramedullary nails, we chose to use regular tibial intramedullary nails as the internal fixation option. Follow-up findings showed that most patients had good outcomes with the use of regular intramedullary nails, with only one case of a peri-implant fracture around the internal fixation. However, the authors still believe that custom-made intramedullary nails are the better choice. Compared to knee joint fusion, the longevity of antibiotic-loaded bone cement combined with tibial intramedullary nailing as the ultimate treatment may be a key focus of attention, but there is currently no specific study reporting on the exact timeframe.Based on our experience, this technique is suitable for elderly, female, slender individuals with low activity levels and significant economic pressures. In conclusion, antibiotic-loaded bone cement combined with tibial intramedullary nailing as last resort treatment can be considered as an alternative surgical option for elderly patients with knee joint bone infection who have experienced multiple failed operations and long-term knee stiffness. Declarations Funding This work was supported by 2019’s program and 2021’s program funded Fuyang Municipal Health Commission (No. FY2019-064 and No.FY2021-051). Authors Contributions Wei Li contributed to conceptualization, formal analysis, funding acquisition, methodology, project administration and writing – original draft; Lei Zhang contributed to data curation, software, visualization and writing – review & editing. Yang Li contributed to investigation, supervision, validation and writing – review & editing. Yong Chen contributed to project administration, resources,validation and writing – review & editing. Liang Bai contributed to data curation, formal analysis, investigation, validation and writing – review & editing. Quankui Zhuang and Zhao Xie contributed to methodology, project administration, supervision, visualization and writing – review & editing; all authors have read and approved the final manuscript. Author information Quankui Zhuang and Zhao Xie contributed equally to this work and should be considered cocorresponding authors. Authors and Affiliations Department of orthopedic, No.2 people’s hospital of Fuyang city, Yingzhou district, Fuyang city, Anhui province, 23600,China. Wei Li，Lei Zhang, Yang Li, Yong Chen, Quan-kui Zhuang Department of Orthopaedics, First Affiliated Hospital (Southwest Hospital), Army Medical University, Chongqing, 400038, the People's Republic of China. Zhao Xie Corresponding authors Correspondence to Zhao Xie or Quan-kui Zhuang Ethical approval and informed consent All patients gave written informed consent before participation in this study and study protocols were approved by ethical committee of No.2 people's hospital of Fuyang city. Competing interests The authors affirm that we have no financial affiliation (including research funding) or involvement with any commercial organization that has a direct financial interest in any matter included in this manuscript. References Boselli E, Allaouchiche B. [Diffusion in bone tissue of antibiotics]. Presse Med. 1999;28:2265–76. Nelson SB, Pinkney JA, Chen AF, Tande AJ. Periprosthetic Joint Infection: Current Clinical Challenges. Clin Infect Dis. 2023;77:e34–45. Gottfriedsen TB, Schrøder HM, Odgaard A. Knee Arthrodesis After Failure of Knee Arthroplasty: A Nationwide Register-Based Study. J Bone Joint Surg Am. 2016;98:1370–7. Yeung CM, Lichstein PM, Varady NH, Maguire JH, Chen AF, Estok DM 2. nd. Knee Arthrodesis Is a Durable Option for the Salvage of Infected Total Knee Arthroplasty. J Arthroplasty. 2020;35:3261–8. Conway JD, Annasamudram A, Abalkhail T, Tom JH, Farley RP, Gesheff M, et al. Functional Outcomes of Knee Arthrodesis for Infected Total Knee Arthroplasty. 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Conversion of cemented revision total knee prostheses to arthrodesis using custom-made arthrodesis modules that preserve the cemented stem anchorage in patients with long-established extensor mechanism insufficiency: A case series. Knee. 2019;26:1117–24. Faure P-A, Putman S, Senneville E, Beltrand E, Behal H, Migaud H. Knee arthrodesis using a custom modular intramedullary nail in failed, infected knee arthroplasties: A concise follow-up note of 31 cases at a median of 13 years post-arthrodesis. Orthop Traumatol Surg Res. 2021;107:102898. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4367527","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":308623915,"identity":"fc235d59-6828-47a2-ad29-0ce49aadae58","order_by":0,"name":"Wei Li","email":"","orcid":"","institution":"Fuyang Second People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Li","suffix":""},{"id":308623916,"identity":"0097bf7b-46f4-44c0-a3d9-7fa6f6c078dd","order_by":1,"name":"Lei Zhang","email":"","orcid":"","institution":"Fuyang Second People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Zhang","suffix":""},{"id":308623918,"identity":"f2d53970-35ae-4dda-a47c-f4eaa82cce41","order_by":2,"name":"Yang li","email":"","orcid":"","institution":"Fuyang Second People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"li","suffix":""},{"id":308623919,"identity":"d5ab7049-e979-4f0e-a610-e94606a69e98","order_by":3,"name":"Yong chen","email":"","orcid":"","institution":"Fuyang Second People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"chen","suffix":""},{"id":308623920,"identity":"342094f9-48b1-4cc1-b3d7-92c80860b2e8","order_by":4,"name":"Zhao Xie","email":"","orcid":"","institution":"Southwest Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhao","middleName":"","lastName":"Xie","suffix":""},{"id":308623921,"identity":"d2d7ec17-2d5f-40fe-8b26-f66253db05fd","order_by":5,"name":"Quankui Zhuang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAv0lEQVRIiWNgGAWjYFACNsYHCQb/5BiYSdDCbPCh4IAxSVrYJGd8OJDYQLQG+fa0BGkegzvp89t5D35gqLGJJqiFsefZAWMeg2e5Gw7zJUswHEvLJWgds0R6QzKPAXPuBmYeAwnGhsOEtbABtRwGakmXb+Yx/kGUFh6JtIONMwwOJzAc5jEjzhYJnmfJDB8M0gw3ALVYJBDjF2CImf9I+GMjL99/xvjGhxobwloYGBJwsInUMgpGwSgYBaMAGwAAyJA796AX0acAAAAASUVORK5CYII=","orcid":"","institution":"Fuyang Second People's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Quankui","middleName":"","lastName":"Zhuang","suffix":""}],"badges":[],"createdAt":"2024-05-04 08:39:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4367527/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4367527/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57864496,"identity":"c5010764-5750-4c47-b5f2-8a7012db7a06","added_by":"auto","created_at":"2024-06-06 15:29:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":4089106,"visible":true,"origin":"","legend":"\u003cp\u003eMultimodal Imaging and Surgical Treatment of Chronic Osteomyelitis in a 74-Year-Old Female Patient. (A) Preoperative photographs illustrating the clinical presentation of the right thigh with suppuration and a stiff, deformed knee joint, symptoms that have been enduring for over 53 years.(B,C,D) Preoperative imaging of the affected limb, including X-ray, computed tomography (CT) scan, and magnetic resonance imaging (MRI), which delineate the extent of the chronic osteomyelitis of the right distal femur. (E) An intraoperative photograph showing en bloc resection of the lesion bone during the stage-1 surgery. (F,G) postoperative anteroposterior and lateral X-ray after stage-1 surgery which involved debridement, bone cement filling, and plate external fixation. (H,I,J,K) intraoperative photo of the stage-2 surgery characterized by antibiotic-loaded bone cement combined with tibial intramedullary nailing as last resort treatment. (L) postoperative X-ray after the stage-2 surgery. (M,N) postoperative photographs of the body after the second-stage surgery.\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4367527/v1/c8b76a2c4161a568630f179f.png"},{"id":59732362,"identity":"5bfeeaf6-851e-4336-8827-e4632cbcf5be","added_by":"auto","created_at":"2024-07-05 12:29:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4397718,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4367527/v1/e20618a8-84d2-4a10-9c5b-a64617bb0312.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The use of antibiotic-loaded bone cement combined with tibial intramedullary nail as last resort treatment in 11 elderly patients with knee joint bone infection","fulltext":[{"header":"1. Background","content":"\u003cp\u003eBone infection has always been a challenging problem in the field of orthopedics, often leading to lifelong disabilities, even endangering life [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. For patients with stiffness, reinfection after knee revision replacement, and a large extent of bone infection, knee joint fusion may be a more ideal surgical option[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Knee joint fusion, while beneficial, comes with several potential disadvantages. One common issue is leg length discrepancy post-surgery, a consequence of shortening the affected limb to enhance bone healing at the fusion site. Studies have reported limb shortening ranging from approximately 2.5 to 5.4 cm associated with knee arthrodesis procedures[\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A second concern is the frequent insufficiency of autologous bone available for patients undergoing this procedure[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Although extensive autologous bone grafting is a recognized method to facilitate healing, factors such as the patient\u0026rsquo;s advanced age and prolonged inactivity can lead to significant osteoporosis, thereby diminishing bone density[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Other notable complications associated with knee joint fusion include persistent infections, nonunion at the fusion site, and elevated healthcare costs[\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecently, some scholars have achieved certain success by using bone cement combined with internal fixation as an ultimate treatment for addressing the limitations of knee joint fusion in patients with knee joint bone infection[\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Since 2014, our team has utilized antibiotic-loaded bone cement combined with tibial intramedullary nail as the ultimate treatment approach for 11 elderly patients with knee joint bone infection.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Materials\u003c/h2\u003e \u003cp\u003eThis is a retrospective study in which we reviewed and analyzed data from 11 patients with knee joint bone infections who were treated at our hospital\u0026rsquo;s Bone Infection Reconstruction Center from July 2014 to July 2022. The cohort comprised 8 females and 3 males with an average age of 74.27 years, with the youngest being 70. Among them, 4 experienced reinfection after knee joint revision replacement and 7 had knee joint bone infection (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). All patients underwent a two-stage treatment approach involving an initial surgery to control the infection, followed by the use of antibiotic bone cement combined with tibial intramedullary nail as the ultimate treatment technique.The surgical methodology was rigorously evaluated and received approval from the Institutional Review Board (IRB) of our hospital\u0026rsquo;s Medical Ethics Committee, adhering to the highest standards of ethical practice and patient consent. All methods were carried out in accordance with relevant guidelines and regulations(IRB No: 20140714-10)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDetails of patients who underwent antibiotic-loaded bone cement combined with tibial intramedullary nail as the ultimate treatment for elderly knee joint bone infection\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge(y)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMain diagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSite\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSide\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStiffness(Y/N)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLength of bone loss(cm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eShortened length of limb(cm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eTimes of surgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eUltimate operation duration\u003c/p\u003e \u003cp\u003e(minuter)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eFollow-up period(month)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChronic osteomyelitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edistal femur\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eleft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChronic osteomyelitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edistal femur\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eright\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReinfection after revision replacement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eknee joint\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReinfection after revision replacement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eknee joint\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChronic osteomyelitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eproximal tibia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eright\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChronic osteomyelitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edistal femur\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eleft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReinfection after revision replacement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eknee joint\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eright\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChronic osteomyelitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edistal femur and proximal tibia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eleft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChronic osteomyelitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edistal femur and proximal tibia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eright\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChronic osteomyelitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edistal femur\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eleft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReinfection after revision replacement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eknee joint\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eright\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003c/span\u003e\u0026plusmn;S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.27\u0026thinsp;\u0026plusmn;\u0026thinsp;3.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e180.27\u0026thinsp;\u0026plusmn;\u0026thinsp;11.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e37.64\u0026thinsp;\u0026plusmn;\u0026thinsp;3.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Operative technique (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/h2\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eStage 1 - Infection Control: The procedure begins by exposing the infected region surrounding the knee joint. Any present internal fixation or prosthetic material in the affected area is removed. The surgical team meticulously debrides the site, removing all inflammatory granulation and necrotic tissue. During this process, tissue samples are collected for subsequent pathological and microbiological analysis. Debridement continues until healthy bleeding bone, often referred to as the \u0026lsquo;paprika sign\u0026rsquo; is evident, indicating the limit of infection clearance. For extensive segments of infected bone, en-bloc resection may be necessary, and patellectomy is performed if deemed essential. The area is then lavaged sequentially with hydrogen peroxide, saline, povidone-iodine solution, and again with saline to reduce the bioburden to a minimal level. The resultant cavity is filled with an antibiotic-loaded bone cement (PALACOS\u0026reg;R\u0026thinsp;+\u0026thinsp;G*,Heraeus Group,Germany), using a mix ratio of vancomycin to cement of 5:1. To maintain structural stability, external fixation is applied, utilizing either dedicated external fixation devices or an external fixator to secure the bone ends.\u003c/p\u003e \u003cp\u003eStage 2 - Definitive Treatment: Approximately 6 to 8 weeks following the initial surgery, contingent upon the patient\u0026rsquo;s clinical presentation, imaging results, and laboratory findings indicating infection control, the second-stage surgery is commenced. This phase involves the use of antibiotic-loaded bone cement combined with tibial intramedullary nail as a definitive therapeutic measure.\u003c/p\u003e \u003cp\u003eBegin the removal process by carefully disassembling the external fixation device or fixator. Reopen the initial surgical incision to access the defect area. Employ an osteotome with precision to chisel away the bone cement that fills the defect. After the cement has been removed, meticulously prepare the terminal bone surfaces to promote an optimal interface and adhesion for the subsequent application of new bone cement. Thoroughly irrigate the site with a sequence of hydrogen peroxide, saline solution, povidone-iodine solution, and another round of saline to cleanse the area.\u003c/p\u003e \u003cp\u003eCareful selection of the tibial intramedullary nail from Double Medical Technology Co., Ltd., China, is imperative, ensuring that its length and diameter are tailored to the patient\u0026rsquo;s specific tibial anatomy. During the procedure, the chosen intramedullary nail is inserted along the tibial medullary canal. It is positioned so that its proximal end can be retracted into the femoral medullary canal for optimal alignment. Once the nail is withdrawn into the correct position, with its end secured within the femoral canal, it\u0026rsquo;s locked in place to ensure stability between the femur and tibia. Throughout the procedure, attention is given to preserving the alignment of the femur and tibia, as well as ensuring limb length equality. Using fluoroscopic guidance, locking screws are carefully driven and tightened at both the proximal and distal ends of the nail to achieve a robust stabilization of the joint.\u003c/p\u003e \u003cp\u003eCommence by thoroughly mixing one sachet of bone cement with the monomer until a homogenous consistency is obtained. Proceed to meticulously pack this mixture into the medullary cavities at both the femoral and tibial ends. This serves to securely anchor the intramedullary nail in place at each extremity. Subsequently, measure the defect and prepare an adequate quantity of the bone cement mixture to fill the void completely. Once the bone cement has been confirmed to have set firmly, place a drainage tube to prevent fluid accumulation. Finally, suture the wound with precision to promote optimal healing.\u003c/p\u003e \u003cp\u003eThree days postoperatively, the patient was able to bear weight with the assistance of crutches.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Outcome measures\u003c/h2\u003e \u003cp\u003ePreoperative, intraoperative, and postoperative documentation must include specific metrics to assess the surgical outcome and patient recovery:\u003c/p\u003e \u003cp\u003ePreoperative Documentation:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eRecord the Western Ontario and McMaster Universities Osteoarthritis Index (WOWAC) score[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] of the knee joint to assess the baseline functional status.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDocument the number of prior surgical procedures performed on the affected limb.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eIntraoperative Documentation:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eMeasure and record the length of the bone defect following debridement of the infected lesion.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eNote the duration of the surgical procedure.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003ePostoperative Documentation:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eDocument the WOWAC score of the affected limb at the final follow-up to evaluate the outcome.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMeasure and record any discrepancy in the length between both lower limbs.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCatalog any surgery-related complications, such as recurrent infections or peri-implant fractures.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Statistical Analysis\u003c/h2\u003e \u003cp\u003eData will be analyzed using IBM SPSS Statistics software, version 26.0. For continuous variables, a one-sample Student\u0026rsquo;s t-test will be utilized to compare the means across groups. Categorical data will be evaluated using the Chi-square test. A P-value of less than 0.05 will be considered statistically significant, indicating meaningful differences between the datasets under examination.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eAll patients successfully completed the surgery, and bone infections were effectively controlled in all cases. Among the patients, 8 out of 11 were female and 3 out of 11 were male, with an average age of 74.27 ± 3.47 years. The average length of bone defect after debridement was 12.09 ± 1.22 cm, and the duration of the last surgery was 180.27 ± 11.06 minutes. The average follow-up time post-surgery was 37.64 ± 11.64 months (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). One case experienced a peri-implant fracture, which was treated with open reduction and internal fixation.\u003c/p\u003e \u003cp\u003ePostoperatively, there was no significant difference in the length of both lower limbs among all patients (0.66 ± 0.21 cm). The knee joint function of patients improved significantly after surgery, with the WOMAC total score significantly higher than preoperatively (141.45 ± 11.75 and 79.09 ± 0.34, P \u0026lt; 0.05). The improvement in function was mainly reflected in pain (26.27 ± 2.45 and 0.00 ± 0.00, P = 0.00) and difficulty in performing daily activities (100.55 ± 8.37 and 59.09 ± 0.34, P = 0.00). However, there was a decrease in knee joint stiffness compared to preoperative levels (15.45 ± 1.63 and 20.00 ± 0.00, P = 0.01) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"±\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"±\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of WOMAC scores of knee joint in the pre-operation and postoperation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003epre-operation\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003epostoperation\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWOMAC pain scores\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c2\"\u003e \u003cp\u003e26.27 ± 2.45\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e0.00 ± 0.00\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWOMAC stiffness scores\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c2\"\u003e \u003cp\u003e15.45 ± 1.63\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e20.00 ± 0.00\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWOMAC function scores\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c2\"\u003e \u003cp\u003e100.55 ± 8.37\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e59.09 ± 0.34\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWOMAC scores\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c2\"\u003e \u003cp\u003e141.45 ± 11.75\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e79.09 ± 0.34\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: 10 points for those who cannot walk or need assistance with crutches\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eKnee joint fusion is a safe and effective treatment option for patients with knee joint bone infections accompanied by stiffness, as well as for patients who experience recurrent infections after knee joint replacement.Literature reports indicate that the fusion rate for knee joint fusion in patients with postoperative infections after knee joint replacement can be as high as 89%[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, some studies have pointed out that while the fusion rate is relatively high in the patients, there is also a higher incidence of complications such as internal fixation failure, delayed bone healing, and pseudarthrosis, which are approximately37.6%[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. These complications may pose a significant burden for some patients. In our study, we applied antibiotic-loaded bone cement combined with tibial intramedullary nailing as the ultimate treatment for 11 elderly patients with knee joint bone infections. After a follow-up period of 37.64 months, the WOMAC scores were significantly improved compared to preoperative scores.\u003c/p\u003e\u003cp\u003ePostoperative limb shortening and a large amount of bone grafting are disadvantages of knee joint fusion for the patients[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].In our study, there was no significant difference in the lengths of the patients’ lower limbs postoperatively, which was better than what is reported in the literature for knee joint fusion patients.For elderly patients, bone quantity has always been a challenging issue due to bone loss. In our study, we not only addressed the problem of limited bone sources but also avoided iatrogenic damage to other parts of the patient’s body.\u003c/p\u003e\u003cp\u003eCustom-made intramedullary nails are biomechanically appropriate for the knee joint fusion, are easy to operate, and have the best therapeutic effect[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29 CR30 CR31\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e–\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. However, its biggest drawback is the high cost.In our study, considering the high cost of custom-made intramedullary nails, we chose to use regular tibial intramedullary nails as the internal fixation option. Follow-up findings showed that most patients had good outcomes with the use of regular intramedullary nails, with only one case of a peri-implant fracture around the internal fixation. However, the authors still believe that custom-made intramedullary nails are the better choice.\u003c/p\u003e\u003cp\u003eCompared to knee joint fusion, the longevity of antibiotic-loaded bone cement combined with tibial intramedullary nailing as the ultimate treatment may be a key focus of attention, but there is currently no specific study reporting on the exact timeframe.Based on our experience, this technique is suitable for elderly, female, slender individuals with low activity levels and significant economic pressures.\u003c/p\u003e\u003cp\u003eIn conclusion, antibiotic-loaded bone cement combined with tibial intramedullary nailing as last resort treatment can be considered as an alternative surgical option for elderly patients with knee joint bone infection who have experienced multiple failed operations and long-term knee stiffness.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by 2019\u0026rsquo;s program and 2021\u0026rsquo;s program funded Fuyang Municipal Health Commission (No. FY2019-064 and No.FY2021-051).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWei Li contributed to conceptualization, formal analysis, funding acquisition, methodology, project administration and writing \u0026ndash; original draft; Lei Zhang contributed to data curation, software, visualization and writing \u0026ndash; review \u0026amp; editing. Yang Li contributed to investigation, supervision, validation and writing \u0026ndash; review \u0026amp; editing. Yong Chen contributed to project administration, resources,validation and writing \u0026ndash; review \u0026amp; editing. Liang Bai contributed to data curation, formal analysis, investigation, validation and writing \u0026ndash; review \u0026amp; editing. Quankui Zhuang and Zhao Xie contributed to methodology, project administration, supervision, visualization and writing \u0026ndash; review \u0026amp; editing; all authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuankui Zhuang and Zhao Xie contributed equally to this work and should be considered cocorresponding authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and Affiliations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepartment of orthopedic, No.2 people\u0026rsquo;s hospital of Fuyang city, Yingzhou district, Fuyang city, Anhui province, 23600,China.\u003c/p\u003e\n\u003cp\u003eWei Li，Lei Zhang, Yang Li, Yong Chen,\u0026nbsp;Quan-kui Zhuang\u003c/p\u003e\n\u003cp\u003eDepartment of Orthopaedics, First Affiliated Hospital (Southwest Hospital), Army Medical University, Chongqing, 400038,\u0026nbsp;the People\u0026apos;s Republic of China.\u003c/p\u003e\n\u003cp\u003eZhao Xie\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding authors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to Zhao Xie or\u0026nbsp;Quan-kui Zhuang\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eEthical approval and informed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients gave written informed consent before participation in this study and study protocols were approved by ethical committee of \u0026nbsp;No.2 people\u0026apos;s hospital of Fuyang city.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors affirm that we have no financial affiliation (including research funding) or involvement with any commercial organization that has a direct financial interest in any matter included in this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBoselli E, Allaouchiche B. [Diffusion in bone tissue of antibiotics]. Presse Med. 1999;28:2265\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNelson SB, Pinkney JA, Chen AF, Tande AJ. Periprosthetic Joint Infection: Current Clinical Challenges. Clin Infect Dis. 2023;77:e34\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGottfriedsen TB, Schr\u0026oslash;der HM, Odgaard A. Knee Arthrodesis After Failure of Knee Arthroplasty: A Nationwide Register-Based Study. J Bone Joint Surg Am. 2016;98:1370\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYeung CM, Lichstein PM, Varady NH, Maguire JH, Chen AF, Estok DM 2. nd. Knee Arthrodesis Is a Durable Option for the Salvage of Infected Total Knee Arthroplasty. J Arthroplasty. 2020;35:3261\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConway JD, Annasamudram A, Abalkhail T, Tom JH, Farley RP, Gesheff M, et al. 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Outcomes of knee arthrodesis following infected total knee arthroplasty: a retrospective analysis of 8 cases. Mod Rheumatol. 2014;24:243\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorona PS, Jurado M, Scott-Tennent A, Fraile R, Carrera L, Vicente M. Uniplanar versus biplanar monolateral external fixator knee arthrodesis after end-stage failed infected total knee arthroplasty: a comparative study. Eur J Orthop Surg Traumatol. 2020;30:815\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoy AC, Albert S, Gouse M, Inja DB. Functional outcome of knee arthrodesis with a monorail external fixator. Strategies Trauma Limb Reconstr. 2016;11:31\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSomayaji HS, Tsaggerides P, Ware HE, Dowd GSE. Knee arthrodesis\u0026ndash;a review. Knee. 2008;15:247\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStahl A, Yang YP. Regenerative Approaches for the Treatment of Large Bone Defects. Tissue Eng Part B Rev. 2021;27:539\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoughlan T, Dockery F. Osteoporosis and fracture risk in older people. Clin Med (Lond). 2014;14:187\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSrivastava M, Deal C. Osteoporosis in elderly: prevention and treatment. Clin Geriatr Med. 2002;18:529\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuyet A, Steinmetz S, Gallusser N, Roche D, Fischbacher A, Tissot C, et al. Fusion rate of 89% after knee arthrodesis using an intramedullary nail: a mono-centric retrospective review of 48 cases. Knee Surg Sports Traumatol Arthrosc. 2023;31:1299\u0026ndash;306.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eB\u0026uuml;y\u0026uuml;kdoğan K, \u0026Ouml;zt\u0026uuml;rkmen Y, Goker B, Oral M, Atay T, \u0026Ouml;zkan K, et al. Early results of a novel modular knee arthrodesis implant after uncontrolled periprosthetic knee joint infection. BMC Musculoskelet Disord. 2023;24:889.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuda AJ, Brachtendorf X, Tinelli M, Wagokh R, Abou-Nouar G, Bischel OE. Low complication rate and better results for intramedullary nail - arthrodesis for infected knee joints compared to external fixator-a series of one hundred fifty two patients. Int Orthop. 2021;45:1735\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElbahri HMH, Abd-Elmaged HMA, Abdulkarim M, Ahmed MMM, Medani MME. Wide resection and reconstruction in a low resource area, cemented nail technique knee arthrodesis; a report of case and surgical technique. Int J Surg Case Rep. 2022;99:107621.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRupp M, Walter N, Ismat A, Alt V. [Polymethyl methacrylate cement coating of intramedullary implants: A new technique for revision surgery with the example of a temporary knee arthrodesis. Video article] Orthopade. 2021;50:758\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHawi N, Kendoff D, Citak M, Gehrke T, Haasper C. Septic single-stage knee arthrodesis after failed total knee arthroplasty using a cemented coupled nail. Bone Joint J. 2015;97\u0026ndash;B:649\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIacono F, Bruni D, Lo Presti M, Raspugli G, Bondi A, Sharma B, et al. Knee arthrodesis with a press-fit modular intramedullary nail without bone-on-bone fusion after an infected revision TKA. Knee. 2012;19:555\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLetartre R, Combes A, Autissier G, Bonnevialle N, Gougeon F. Knee arthodesis using a modular customized intramedullary nail. Orthop Traumatol Surg Res. 2009;95:520\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAparicio G, Otero J, Bru S. High Rate of Fusion but High Complication Rate After Knee Arthrodesis for Infected Revision Total Knee Replacement. Indian J Orthop. 2020;54:616\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobinson M, Piponov HI, Ormseth A, Helder CW, Schwartz B, Gonzalez MH. Knee Arthrodesis Outcomes After Infected Total Knee Arthroplasty and Failure of Two-stage Revision With an Antibiotic Cement Spacer. J Am Acad Orthop Surg Glob Res Rev. 2018;2:e077.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGallusser N, Goetti P, Luyet A, Borens O. Knee arthrodesis with modular nail after failed TKA due to infection. Eur J Orthop Surg Traumatol. 2015;25:1307\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWood JH, Conway JD. Advanced concepts in knee arthrodesis. World J Orthop. 2015;6:202\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhite SP, Porteous AJ, Newman JH, Mintowt-Czyz W, Barr V. Arthrodesis of the knee using a custom-made intramedullary coupled device. J Bone Joint Surg Br. 2003;85:57\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYeoh D, Goddard R, Macnamara P, Bowman N, Miles K, East D, et al. A comparison of two techniques for knee arthrodesis: the custom made intramedullary Mayday nail versus a monoaxial external fixator. Knee. 2008;15:263\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePutman S, Kern G, Senneville E, Beltrand E, Migaud H. Knee arthrodesis using a customised modular intramedullary nail in failed infected total knee arthroplasty. Orthop Traumatol Surg Res. 2013;99:391\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFr\u0026ouml;schen FS, Friedrich MJ, Randau TM, Gravius S, Gravius N. Conversion of cemented revision total knee prostheses to arthrodesis using custom-made arthrodesis modules that preserve the cemented stem anchorage in patients with long-established extensor mechanism insufficiency: A case series. Knee. 2019;26:1117\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFaure P-A, Putman S, Senneville E, Beltrand E, Behal H, Migaud H. Knee arthrodesis using a custom modular intramedullary nail in failed, infected knee arthroplasties: A concise follow-up note of 31 cases at a median of 13 years post-arthrodesis. Orthop Traumatol Surg Res. 2021;107:102898.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"reinfection after knee revision replacement, knee joint bone infection, bone defect, tibial intramedullary nailing, antibiotic-loaded bone cement","lastPublishedDoi":"10.21203/rs.3.rs-4367527/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4367527/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003eThe management of bone infections has always posed a challenge in the field of orthopedics, and geriatric knee joint bone infections are even more difficult. In this study, we aimed to assess the clinical efficacy of using antibiotic-loaded bone cementcombined with tibial intramedullary nail as a last resort treatment option for geriatric knee joint bone infection patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods \u003c/strong\u003eThe retrospective study was conducted on 11 elderly patients with knee joint bone infection. The cohort comprised 3 male and 8 female patients, with an average age of 74.27±3.47years. Of these patients, 4 patients experienced reinfection after knee revision replacement, while 7 patients had knee joint bone infection.After stage-1 infection control, all patients underwent a stage-2 treatment using antibiotic-loaded bone cement combined with tibial intramedullary nail as the ultimate treatment approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eAll patients’ infections were effectively controlled. The average length of bone defect after debridement was \u0026nbsp;12.09±1.22cm. The duration of the stage-2 operation averaged180.27±11.06minutes. Postoperatively, there was no significant discrepancy in the length of the patients’ lower limbs. All patients experienced a significant enhancement in knee joint function, as indicated by the decrease in WOMAC scores from \u0026nbsp;141.45±11.75preoperatively to \u0026nbsp;79.09±0.34postoperatively. Pain levels saw a profound reduction, plummeting from 26.27 ± 2.45 to a non-existent 0.00 ± 0.00. Additionally, there was a substantial improvement in performing daily activities, rising impressively from 59.09 ± 0.34 to 100.55 ± 8.37. However, an increase in joint stiffness was noted, worsening slightly from 15.45 ± 1.63 to 20.00 ± 0.00.One case of peri-implant fracture occurred.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003eAntibiotic-loaded bone cement combined with tibial intramedullary nailing as last resort treatment can be considered as an alternative surgical option for elderly patients with knee joint bone infection who have experienced multiple failed operations and long-term knee stiffness.\u003c/p\u003e","manuscriptTitle":"The use of antibiotic-loaded bone cement combined with tibial intramedullary nail as last resort treatment in 11 elderly patients with knee joint bone infection","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-06 15:29:10","doi":"10.21203/rs.3.rs-4367527/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e71d608b-b1e2-4cd3-b419-cf8e013a8647","owner":[],"postedDate":"June 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-05T12:21:13+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-06 15:29:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4367527","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4367527","identity":"rs-4367527","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}